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ONAPPLICATION FOR WELLIPUMP PERMIT <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES• <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUEMomD <br /> ntal <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IIn R <br /> TANOM1 INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE NRTN BAN <br /> JOAQUIN COUNTY DEVELOPMENT TI.F11�1,CHAPTER 8n1116.3 AND THESTANDARDSOF BAN JOAQUIN COUNTY PUBLIC DE/ALLTH SERVICES. <br /> ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR AAPNI 8+8•-r /V/Ur-6�1 ('enfery f CITI �5 /I•�(.i/C,�/E//�/ PAMEL SIZE/APN/ <br /> OWNER'S NAME l.. ��L` L���^� ✓7(J� �/� ADDRESS /, C( PHONE# <br /> CONTRACTOR C-LT/�Llm ADDRESS & <br /> _'_ 7G�C - I7 UCI �Z768 PHONE# <br /> BUB CONTRACTOR ADDRESS UC# <br /> PHONE I <br /> TYPE OF WELUPIIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTAI LATION ❑ WELL SYSTEM REPAIR '❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> OF FV MPI <br /> (TYPE <br /> IJNew 13P,.Ir N.P. DEPTH PUMP BE .T_" FIRST WATER LEVEL O <br /> �,/ <br /> ❑ OUT-Or-SERVICE WELL - r El GEOPHYSICAL WELL# �1 SOIL BORINO 6 dro It/Gl-I B <br /> El DESTRUCTION- <br /> !U#E�e✓ .xrArl ,fir <br /> INTENDED USE TYPE OF WELL CONSTRUCTION BPECIFICAtIONB <br /> ❑ INDUSTRIAL ❑ AOPEN BOTTOM VIA.OF WELL EXCAVATMN DIA.OF CONDUCTOR CASINO <br /> ❑ OOMESTICIPRIVATE ❑GRAVEL PACK/SIZE_ , TWIMEXASING/STEEI/PVC D <br /> DIA.OF WWELL C�$ING D <br /> ❑ PUBLICARRACIPPL ❑DRIVE4 DEPTH OF GROUT SEALSPECIFICATIOti R <br /> ❑ IRRIGATIONIAG 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑ MONITORING •//I.c IT GROUT SEAL PIMPED: ❑Vu [IN. CONCRETE PEDESTAL SY DRILLER:❑Yu DiuS <br /> APPRO%'DEPTH 0"J JG- LOCKING CHESTER BO USTOVE RPE a <br /> PROPOSED CONSTRLICTION/MLUNG METHOD: MUD ROTARY AIR ROTARY AUGER L/ CABLE OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS A,,A I'UN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT W THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT 08 ISSUED.I SI/ALL NOT EMPLOY PITAMNS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIED <br /> THE FOLLOWING: •I,el Ire THAT IN THEE,PERFORMANCE OF THE M FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> EA <br /> CAUFORNIA.' T CANT MUST MICE 24 HOURS IN DVAN R+ U R XD Ne ��140 411425. COMPLETE DRAWINO AT LOWER AREA PROVIDED..�— <br /> DI#r,e!% <br /> KO N IDrew to See.)SON. •to �✓ <br /> 1. NAMES OF STREETS OR WADS NEAREST TO BOUNDING THE PROPERTY. I. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PIUPOSED <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS'. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION GF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PHOPEnrY. <br /> R��E <br /> SAY ;. 81997 <br /> SAN JUAuUIN CUUN);T <br /> PUHLIC HEALTH SERVICES <br /> ENV.IR(?NMENTA�HEALTH DIV{SIO <br /> I <br /> DEPARTMENT USE ONLY <br /> BY <br /> F c <br /> Appllealen Aueplal Del. / Aru <br /> GmU Impevllon BY Dae Penp Impmllen By D.t. <br /> De.msGan ImpuGen BY D.I. <br /> Cemman.: <br /> ACCOUNTING,ONLY: AIDI FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED /CASH I REC13VED BY DATE PFAMITISERWCE REQUEST NUMBER INVOICE <br /> Pub.Health Sam.-Enviro.173(3196) <br />